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TABLE OF CONTENTS

TITLE PAGE Page Number


I. ACKNOWLEDGDMENT 2
II. SIGNIFICANCE OF STUDY 3
III. RATIONALE OF STUDY 4
IV. OBJECTIVE OF STUDY 5
V. INTRODUCTION 6
VI. PATIENT PROFILE 7
VII. NURSING HEALTH HISTORY 8

 History of Present Illness 8


 Supportive Measures 8
 Post Partum Care 8
I. PHYSICAL ASSESSMENT 9-11
 Appearance 12
 Vital Signs 12
 Measurements 12
 Cephalocudal Approach 13-20
 Gordon’s Level of functions 21-26
I. ANATOMY AND PHYSIOLOGY 27
II. PATHOPHYSIOLOGY 28-29
III. MEDICAL AND SURGICAL MANAGEMENT 30-31
IV. LABORATORY EXAMINATIONS 32-33
V. DRUG STUDY 34-40
VI. NURSING CARE PLAN 41-51
VII. PLANNING AND DISCHARGE 52-53
VIII.EVALUATION 54
IX. REFERENCE 55

I. ACKNOWLEDGMENT

1
My experience in Gabriela Silang District Hospital at OB-GYNE have taught us a lot of
things as a person and that is to now and to love ourselves better.

For their generous help, our group would like to thank our Maa’m Dumlao our class
adviser in NCM 204 for importing us on themselves on us the values of discipline and hard
work. She taught us a lot of things that will help us in our journey as nursing students got mostly
importantly as how to become a better person.

To the Staff for continuing to inspire us the value of generosity. The importance of
helping others, being the best in her field doesn’t stop her to help these patients bring back their
lives.

To my patient who in a way helped and very cooperative the task that was assigned to
them and they let us to know them more as a better person.

Severe Pre
Eclampsia
II .SIGNIFICANCE OF THE STUDY

2
In the pursuit of this case study entitled Pregnancy Induced Hypertension: Severe
Eclampsia it cites the important, responsiveness or relevance of expected outcomes
investigations and its probable effects on mothers who are high risk and nursing practice
particularly in Maternal and Child Nursing. This case study emphasize the significant
contribution to its target population especially pregnant women and her family, Nursing
profession, Nursing Service, Nursing education, Nursing students and its implications to future
researchers.
Beneficiaries of Research Studies in Nursing include the following Sectors:
1. The Nursing Profession as a whole: To improve the quality of Maternal and Child care
by reducing the morbidity and mortality rate who are high risk of Toxemia. To identity
and implement the Health Goals related to complications of pregnancy which give
specific measurement to achieve these goals like eliminating the risk factors.

2. The public as end users: To increase knowledge especially those mothers by identifying
and describing complications of Pregnancy Induced hypertension that takes place a
pregnant woman and her fetus at high risk.

3. Nursing Service: To create or develop Hospital operations or training to provide


orientation and staff development particularly in care of childbearing and its family.

4. Nursing education. To identify vital competencies to developed in nursing students,


particularly proficiency of roles and functions in patients who are experiencing this kind
of complications.

5. Nursing Practitioners. To use critical thinking to analyze ways of nurses can help how to
prevent complications and its prompt treatment. This will gain added knowledge and
expertise for individual practitioners that serve as a guide in decision making.

6. Finally, Nursing Students and Researches. To identity areas of Nursing care related to
high risk that could benefit from additional nursing research in terms of case study that
serve as an application of evidenced based practice. This case study will serve as a future
reference to the next researcher.

Severe Pre
Eclampsia

III. RATIONALE OF THE STUDY

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1. Identify expected outcomes to minimize the risks to a pregnant woman and her fetus
which complications of pregnancy occur.

2. Formulate Nursing Diagnosis that addresses the needs of a woman and her family
experiencing Pregnancy Induced Hypertension.

3. Planning Interventions to meet the needs and promote optimal well being for a
woman and her family during complications occurs.
4.
Implement Nursing care especially to a woman who has developed toxemia.

5. Evaluate outcomes for effectiveness and achievement of Nursing care

IV. OBJECTIVE OF THE STUDY

1. Establish rapport with the patient by promoting nurse-patient interaction based on trust.

2. Assess the patient systematically.

3. Know the etiology and complications of Pregnancy Induced Hypertension and how to

prevent it.

4. Understand the pathophysiology of the disease in relation to the normal anatomy of the

affected parts.

5. Interpret and analyze different laboratory results and their significance to the disease and

the patient.

6. Understand the prescribed medications necessary for the treatment of the disease

including their mechanisms of action, indications, contraindications, side effects, and

nursing responsibilities.

7. Construct a systematic, measurable, attainable, realistic, and time bounded nursing care

plans that cater to the patient’s needs based on the health assessment done.

8. Formulate an appropriate discharge plan based on the patient’s needs.

9. Develop the right attitude in dealing with patients with this condition by understanding

their behavior and feelings.

Severe Pre
Eclampsia

V. INTRODUCTION

4
Hypertension refers to an intermittent or sustained elevation in diastolic and systolic
blood pressure. It is called if blood pressure above the normal range 140/90 and above.

In pregnancy induced hypertension is a form of high blood pressure that occurs of all
pregnancy that usually develops in the 2nd or 3rd trimester after 20 weeks and solved 6 weeks of
postpartum. Some researcher proven as authorities failed to find any toxins. It’s also called
Toxemia or preeclampsia. It s categorized as Preeclampsia, eclampsia with three clinical
manifestation edema, hypertension and proteinuria. The primary differentiating factor between
preeclampsia and eclampsia is the presence of convulsion.

Gestational Hypertension –sustained blood pressure elevation of greater than or equal to


140/90 mmhg after 20 weeks of pregnancy. Hypertension without edema and proteinuria. No
damage to fetus and unremarkable physical findings blood pressure normalize during post term.

Transitional hypertension- hypertension before 24 weeks of gestation.

Chronic or Preexisting Hypertension –hypertension before 20 weeks and not solved 6


weeks of postpartum

HELLP Syndrome- is a variation of Pregnancy Induced Hypertension for the common


symptoms that occur: Hemolysis, elevated liver enzymes and low platelets. Women develop
HELLP syndrome is unknown. It occurs in both multigravidas and primigravidas.

In my case study I will focus the three types of Preeclampsia namely Mild eclampsia,
Eclampsia and particularly Severe Preeclampsia. Eclampsia is sustained blood pressure
elevation after 20 weeks of gestation in the absence of preexisting hypertension. A potential
serious conditions as it occurs only in pregnancy.

Mild Eclampsia-a blood pressure of 140 or an increase of 30 mmHg taken on two


occasions at least 6 hours apart. The diastolic value of blood pressure is extremely important to
document because it is the pressure that best indicates the degree of peripheral spasm. With mild
eclampsia, in addition to the hypertension a woman has a proteinuria (1+or2+ on a reagent test
strip on a random sample). Many women show trace of protein during pregnancy. Actual
proteinuria is said to be exist when it registers as at least 1+or more (this represents a loss of
1g/l).Occasionally women have orthostatic proteinuria( on long periods of standing, they excrete
protein; at best rest they do not). If proteinuria is present without other signs of PIH (no
hypertension and no edema), check to see when the specimen was tested. This may reveal that
orthostatic proteinuria, not preeclampsia maybe the cause of protein in her urine.

Severe Pre
Eclampsia

Edema develops as mentioned because of the protein loss, sodium retention and lowered
glomerular filtration rate. Edema begins to accumulate in the upper part of the body. A weight

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gain of more than 2 lb/week in the second trimester or 1 lb/week in the third trimester usually
indicates abnormal tissue fluid retention. This is likely to be the first symptom a woman notices,
or maybe discovered when a woman is weighed at a prenatal visit. Noticeable edema may or
maybe me present when this sudden increase in weight first occurs.

Severe Preeclampsia- a woman has passed mild to severe preeclampsia when her blood
pressure has risen to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two
occasions 6 hours apart at bed rest ( the position in which blood pressure is the lowest) or her
diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria 3+or 4+on a
random urine sample or more than 5 grams in 24 hours sample and extensive edema is present.
With severe preeclampsia, the extreme edema will be noticeable as puffiness in a
woman’s face and hands. It is most readily palpated over bony surfaces, such as over the tibia on
the anterior leg, the ulnar surface if the forearm, and the cheekbone, where the sponginess of
fluid-filled tissue can be palpated against the bone.
Some women have severe epigastric pain and nausea and vomiting, possibly due to
abdominal edema or ischemia to the pancreas and liver. If pulmonary edema develops, a woman
may report feeling short of breath. If cerebral edema occurs reports may be voiced of visual
disturbances such as blurred vision or seeing spots before the eyes. Cerebral edema also
produces symptoms of severe headache and marked hyperreflexia and perhaps ankle clonus.

Severe Pre Eclampsia

VI. PATIENT PROFILE


General Data

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 Name: Maria Erminda Bisoc De Giya
 Age: 31 year old
 Date of Birth: July 10, 1977
 Civil Status: Single
 Religion: Roman Catholic
 Address: Agagrao,Santa Maria Ilocos Sur
 Educational Background: High School Graduate
 Occupation: Housewife
 Name of Siblings: Jake 13y/o Abby 11 y/o, Katrina10 y/o, Mark Angelo
8y/o, Vernel7y/o
 Name of Husband: German R. Mendoza
 Date of Admission: November 25, 2008
 Time of Admission: 3:40 pm
 Date of Discharge November 28, 2008
 Chief Complaint: Epigastric pain accompanied with nausea and vomiting
 Last Menstrual Period: March 27,2008
 Expected Date of Confinement: January 3, 2009
 Service Department: Obstetrics and Gynecological Ward
 Initial Diagnosis: Pregnancy Uterine 34-35 weeks Age of Gestation T/S
Intrauterine Fetal Gravida6 Para5 (6-0-0-4) Preeclampsia Severe
 Final Diagnosis: Pregnancy Uterine 34-35 weeks Age of Gestation
Delivery operatively to an baby boy Gravida6 Para6 ( 6-0-0-5)
Preeclampsia Severe
 Attending Physician: Dr. Nancy Rafanan
 Attending Anesthesiologist: Dr.Melquiades Rosario
 Title Operation Performed: 1 degree LSLS with BTL Live Baby out at
6:30 p.m.

Severe Pre
Eclampsia

VII .NURSING HEALTH HISTORY

HISTORY OF PRESENT ILLNESS

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Ms. De Giya is not aware that she’s pregnant based on my interview I was really
doubtful and I even let my best friend who was duty at OB Ward that to asked again regarding
her pregnancy. I was shocked she told me that she’s not aware that she’s pregnant despites of
having a 5 kids I was mere impossible. I was thinking that time maybe she’s having a postpartum
blues but definitely she’s not base in my assessment. She’s was not able to have any opportunity
to have a pre natal check up and she was not able to feel any pregnancy discomfort. Ms. De Giya
is non-diabetic and hypertensive. He has no known allergies and no history of surgery.

PHYSICAL EXAMINATION

Upon admission, Ms De Giya was examined as awake, conscious, coherent, cooperative,


alert and experiencing epigastric pain accompanied with nausea and vomiting. Headache is also
present as one of her complaint. Edema is noticeable in her fingers and feet despite she’s kinda
fat. She has equal chest expansion, clear breath sounds with no crackles and no wheezing.
Examination of the heart showed no murmurs and has normal rate and regular rhythm. Vital
signs were as follows: BP = 170 / 100 mmHg, CR = 100 bpm, RR = 21 bpm, and temperature =
37.5ºC.

SUPPORTIVE MEASURES

Her family is very supportive in terms of having a new baby in their family. Despites her
parents are already dead her husband is the one who’s giving the finances in the family he’s a
construction worker. His earning is not enough to support all their needs. The eldest is lucky
enough to go to school. The others siblings just stay at home. There are good relatives whom she
considered charitable sometimes they share their used clothes, food and sometimes money. If
there are anyone who’s sick in the family she’s trying her best to go to the health center near at
her place. Sometimes she’s hesitant to go because the services are not good and the nurses are
masungit as she told me during my interview. In spiritual aspect of supportive measures she’s
very religious person and devoted to Mother Mary.

POSTPARTUM CARE

There are many believes/ practices that Ms. De Giya mentioned to me. She told me that
she need to buy the red and black bracelet to drive a way the evil forces. In terms wearing of
clothes. She believed that never wear clothes without sleeves, backless or flimsy so that the
breast won’t be exposed to air and prevent lost of milk. In their family giving names are usually
come from the couples. The father and mother are the one who decides in giving names.

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VIII. PHYSICAL ASSESSMENT
APPEARANCE

During
Techniques Normal Findings Before Hospitalization Hospitalization Interpretation

1. Mood and Inspection Gestures and Ms. De Giya is able to She shows appropriate The patient has undergone classical
Affect expressions are shown do activities of daily facial expressions operation. She is in pain with a scale
while taking. Responds living thus she is able accompanied with pain of 3 out of ten and so, at times shows
to outside stimuli. Does to work as house wife. and gestures. She is irritability. She limits his movements
not show fatigue and She shows appropriate irritable at some times to lessen post-op pain
agitation. Talks at gestures and facial
moderate speed. expressions
Responses are
appropriate to the
situation.

2. Signs of Inspection No signs of pain, Ms. De Giya frequently Ms. Giya endures pain The patient usually feels distress
distress difficulty on breathing, feels pain on her lower on the abdomen and during post operative operation
and anxiety. The client abdomen, headache and show a little distress because of the weaning off
is relaxed and at ease vomiting. when she’s moving so anesthesia.
she prefer sitting to
make her more
comfortable

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3. Posture Inspection Points between the Points between the There is proper Body alignment was not fully
eyes, collar bone, breast eyes, collar bone, breast alignment of the points assessed because she’s breastfeeding
bone, pubic area and bone, pubic area and between the eyes, collar her newborn baby and she prefer
midpoint between midpoint between bone, breast bone and sitting down.
ankles are properly ankles are properly pubic area and
aligned. The three aligned. The three midpoint between the
natural curves at the natural curves at the ankle the back are
back are visible from back are visible from visible from the sides
the sides: The the sides: The
shoulders, hips and the shoulders, hips and the
knees are of equal knees are of equal
height from the front: height from the front:
Head is held straight, Head is held straight,
not tilted or turned to not tilted or turned to
one side: Little bumps one side: Little bumps
of the spine is in of the spine is in
straight line down the straight line down the
center of the back center of the back

4. Body Inspection There are no voluntary No involuntary No observed Patients body movements are normal
movements movements. Has movements before involuntary through there is little limited range
coordinated movements hospitalization. Patient movements. Patient has of motion because of the post
can perform wide range limited range of motion operation that was done.
of motion. Movements because of the surgery
are coordinated undergo.

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Inspection Clothes are clean. Nails Ms. De Giya usually Since the first day of The patient has limited
1. Hygiene and are properly trimmed. takes a bath two times a hospitalization Ms. De to do activities of daily
Grooming There is no presence of day. Clothes are Giya was not able to living because of the
bad breath changed frequently or take a bath and brush operation that was
as necessary. Oral care her teeth. Her clothes undergone.
is done twice a day and are changed every other
nails are trimmed as day. The patient has no
long necessary halitosis. Her nails are
trimmed but there is still
presence of dirt on the
sides. No body odor
was noted during the
assessment

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Inspection The type of clothing Ms. De Giya wears Ms. De Giya wears Ms. Giya wears clothes
2. Type of worn is appropriate for clothes with light cotton sleeves and in which she feels
clothing the temperature and materials like cotton abdominal binders after comfortable. No skinny
weather condition. and polyester. She often the surgery. She usually jeans and skimpy shorts.
wears cotton shirts and uses blanket to drape She prefer loosen shirts
maong shirts her lower extremities because of the incision
on her abdomen

VITAL SIGNS

VITAL SIGNS NORMAL RANGE ACTUAL FINDINGS INTERPRETATION


Temperature Young Adult: 36.1-37.6 36.4 Normal
Pulse Rate Young Adult:60-100 100 beats per minute Normal
Respirations Young Adult:12-20 19 cardiac per minute Normal
Blood Pressure Middle Adult: Systolic: 95-140 mmHG Diastolic: 60-90 mmHg Systolic: 170mmHG Diastolic 100 mmHG Severe Hypertension

MEASUREMENTS

FINDINGS INTERPRETATION

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BMI is 22 which is within not the normal
Height 5 feet and 5 inches/1.65 cm range (28-30) ** BMI computed as
follows: BMI=wt. (kg)/ht. meter square
Weight 135 lbs
30-60 cc/hr. *No urinalysis test was indicated for Normal urine output
Urine Output proteinuria findings was based on the patient itself

CEPHALOCAUDAL APPROACH

1. SKIN

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATIONS


Intact condition. Appropriate
Inspection distributions of pigmentation Intact condition. Decrease in Dry skin due to not taking a
Skin Palpation decrease in skin turgor due to turgor. Dry skin. bath for how many days
decrease production and
sebaceous glands. Warm to
touch

2. HEAD

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATIONS


Proportional to the size of the Proportional to the size of the
Inspection body/round/ with prominence body/round/ with prominence

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Skull Palpation on the frontal area and the on the frontal area and the Normal
occipital are posterior, occipital are posterior,
symmetrical in all planes symmetrical in all planes
gently curved gently curved
Female pattern graying and Receding hairline. Black in Dull and oily hair because his
Hair Inspection loss of hair is normal. coarse color. There’s no gray hair hair was never
or fine in texture and oily in texture washed/shampooed since
admission

White, clean free from White, free from masses, Hair never
Inspection masses, lumps scars, nits lumps, scar, lice, nitz and washed/shampooed since
Scalp Palpation dandruff and lesions, no area lesions. No area of admission hence presence of
of tenderness tenderness. Dandruff is dandruff on the scalp
present
Oval/round/oblong/heart Round. Symmetrical and no
Face Inspection shaped. Symmetrical. With involuntary movements. Normal
wrinkles and no involuntary Color of face is even.
movements Wrinkles are not present

3. EYES

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


Eyes Inspection Parallel evenly placed, Parallel evenly placed, Normal
symmetrical, non protruding symmetrical, non-protruding
with scant secretions. No with scant secretion. No

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presence of eye bags presence of eye bags
Eyebrow Inspection Symmetrical. Evenly Symmetrical. Evenly Normal
distributed and parallel with distributed and parallel with
each other each other
Eyelashes Inspection Black evenly disturbed and Black evenly disturbed and Normal
turned outward. turned outward
Eyelids Inspection Upper lids cover the small Upper lids cover the small Normal
portion of the iris of cornea portion of the iris of cornea
and sclera when they are and sclera when they are
open. open

Sclera Inspection White and clear White and clear Normal


Cornea Transparent, shiny and Transparent, shiny and Normal
Inspection smooth. smooth.

Pupils Inspection Round and equal and reacts Round and equal and reacts
to light and accommodation to light and accommodation Normal

Visual Acuity Inspection Visual acuity by snellen Visual acuity by snellen


chart that is less than 20/20 chart that is less than 20/20 Normal
in vision in vision

Iris Inspection Proportional to the size of the Proportional to the size of the
eyes, round, black and eyes, round, black and Normal
symmetrical symmetrical

4. NOSE

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BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
I
Nose Inspection In the midline, symmetrical n the midline, symmetrical Normal
Palpation and patent and patent

Internal Nares Inspection Clean and pinkish with few Without secretions and thin Normal
cilia cilia
Septum Inspection Straight Straight Normal

5. MOUTH

16
BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Pinkish, symmetrical with Pinkish, symmetrical with


Lips Inspection margin well-defined, smooth margin well-defined, smooth Normal
and moist and moist

Smooth, moist and has no Smooth, moist and has no


Gums Inspection discharge discharge Normal

32 permanent teeth, well Presence of dental carries and


Inspection aligned free from caries, no plaque. With yellowish Due to poor oral hygiene
Teeth filling and no halitosis discolorations on the teeth

Large or medium red or pink Medium light pink and freely


slightly rough on top smooth movable. No lesions Normal
Tongue Inspection along the lateral margin moist
shiny and freely movable
Frenelum Inspection Midline, straight and thin Midline, straight and thin Normal
Dark discoloration seen and Poor oral hygiene and dental
Buccal Mucosa Inspection Pinkish, smooth and moist smooth moist check up

Soft Palate Inspection Pinkish, smooth and moist Light pink, smooth and moist Normal
Hard Palate Inspection Pinkish, smooth and moist Light pink, smooth and moist Normal
Uvula Inspection At the center, freely movable At the center, freely movable Normal
and symmetrical and symmetrical
Tonsils Inspection Pinkish not inflamed Pinkish not inflamed Normal
Voice Inspection No hoarseness and well No hoarseness and well Normal
modulated modulated

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1. NECK

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


Inspection Proportional to the size of Proportional to the size of
the head. Symmetrical and the head symmetrical and

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Neck straight. Freely movable straight. Freely movable Normal
without difficulty without difficulty

Palpation No palpable lumps or


tenderness

2. THORAX

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


Inspection Chest symmetric. Spinal Chest symmetric. Spinal
column is straight. Skin column is straight. Skin
intact. Full and symmetric intact. Full and symmetric
Anterior and Posterior chest expansion. Bilateral chest expansion. Bilateral
Thorax symmetry of tactile fremitus. symmetry of tactile fremitus.
Normal
Palpation No tenderness No tenderness

Auscultation No adventitious breath sound No adventitious breath sound


Inspection Color of the skin is even. Color of the skin is even.
Uniform in movement. Uniform in the movement. Normal
Abdomen umbilicus is the center There’s an small incision
midline of the abdomen.

Palpation Liver is not palpable. No Liver is not palpable. No Normal


tenderness tenderness

3. BREAST

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


Breast Inspection No masses and lumps No masses and lumps Normal
Palpation
Areola Inspection Dark in color in contrast to Dark brown. No masses and Normal

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Palpation surrounding skin. No masses, lesions
lumps and lesions
Nipples Inspection Size is proportional. No Size is proportional. No Normal
discharge or secretions discharge or secretions

4. CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


No presence of murmurs. No presence of murmurs.
Point of maximal pulse on Point of maximal pulse on
Heart Auscultation the 5th ICS at MCL. S1 and the 5th ICS at MCL. S1 and Normal
S2 heart sounds heard clearly S2 heart sounds heard clearly
at four anatomic site: at four anatomic site:
aortic,pumonic,incuspid,and aortic,pumonic,incuspid,and
apical apical

No jugular vein distention. No jugular vein distention.


Central vessels Palpation Carotid arteries pulsate fully Carotid arteries pulsate fully Normal
with thrusting quality with thrusting quality
Peripheral perfusion Inspection Skin color is pink Skin color is pale Poor blood oxygen supply
Palpable. Pulsate fully with Radial pulse (left and right):
Peripheral pulses Palpation thrusting quality Pulsate fully with thrusting Normal
quality

5. UPPER EXTREMITIES

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BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Arms Inspection Able to tolerate wide range Able to tolerate wide range Normal
of motion. No difficulty upon of motion. No difficulty upon
bending and stretching bending and stretching

Shoulders Inspection Able to tolerate wide range Able to tolerate wide range Normal
of motion. No difficulty upon of motion. No difficulty upon
bending and stretching bending and stretching

Elbows Inspection Able to tolerate wide range Able to tolerate wide range Normal
of motion. No difficulty upon of motion. No difficulty upon
bending and stretching bending and stretching

Wrist Inspection Able to tolerate wide range Ms De Giya is experiencing Edema is one of the clinical
of motion. No difficulty upon edema since admission manifestation of severe
bending and stretching preeclampsia

Hand and Fingers Inspection Able to tolerate wide range Ms De Giya is experiencing She’s experiencing severe
of motion. No difficulty upon edema since admission pre eclampsia. Edema is one
bending and stretching of the triage of eclampsia

Nails Inspection Convex, angle of nail plate Convex, angle of nail plate Normal
about 160 degree smooth about 160 degree smooth
texture and intact epidermis texture and intact epidermis

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6. LOWER EXTREMITIES

BODY PARTS TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


Able to perform wide range Able to perform wide range
Hip Inspection of motion of motion Normal
Able to perform wide range Presence of edema Edema is one of signs and
Leg of motion symptoms sever eclampsia
Inspection

Inspection Able to perform wide range Presence of edema Edema is one of the
Knee of motion complications of severe
eclampsia
Able to perform wide range Able to perform wide range
Face and Toes Inspection of motion of motion Normal

Convex, angle of nail plate Convex, angle of nail plate


Nails Inspection about 160 degree, smooth about 160 degree, smooth Normal
texture and intact epidermis texture and intact epidermis

GORDON’S LEVEL OF FUNCTIONING


Approach Before Hospitalization During Hospitalization Interpretation Analysis

22
P-Psychological

1. Health Perception/ Ms. De Giya had previous Ms. De Giya was cooperative The patient still has a belief in Cultural healing beliefs reflect a
Health Management hospitalization due to normal during the treatment. Her data traditional practices. Only specific cultural group’s
delivery last 2006 in Gabriela like her last menstruation when she was informed of the orientation to health and illness.
Silang Hospital. She has no period, age of gestation, necessary a fact pertaining to These beliefs often have great
known to allergies. She is weight, age and expected her conditions that she realizes impact on whether the patient
considering a manghihilot confinement was gathered for that pre natal check up is very gets well. People who have
when consulting for her her treatment, and even she’s important especially she’s a limited access to scientific health
pregnancy. Only when very anxious and experiencing multigravida. Upon learning care may turn to folk healing or
complications occurs pain by that time. Dr. Nancy her condition, she regard for folk medicine. Folk medicine, in
especially in her case severe Rafanan her attending health has improved contrast, to biomedical health
pre eclampsia worsened that physician explained her dramatically care is thought to be more
she have chose to seek condition that she must humanistic.
professional health like the undergo surgery so that her
rural health unit in their complications will not worsen. Illness brings about changes in
barangay. She considered She regards health as one the both the individual and in the
health as one of the least priorities in life and has family. The changes that may
priorities in life due to expressed willingness to treat occur in the family include
financial constraints her medical and surgical demands on time, increased
condition anxiety about the outcome of
illness and financial problems.

Sources:
Foundations of Nursing by
Barbara Christensen
2nd edition p.118
Fundamentals of Nursing by
Kozier 7th edition p. 183, 212,
178

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2. Self-perception/ Self- Ms. De Giya is cheerful and Ms. De Giya is not married Patient, though not aware of Self-concept is how person
concept Pattern active. She has confidence in any at church or civil her condition. Her life is feels about self (self-esteem
herself and readily accepts job wedding. She’s very normal . She doesn’t know and perceives the physical
offers from her friends. dedicated being housewife that she’s at risk because in self. Self- concept affects how
Between offers of work, she doing household chores, the first place she doesn’t people view and handle
spends most of her time at doing the laundry, cleaning know that she’s pregnant situation such attitudes can
home taking good care of her her house and taking good affect health practices and
5 children. care of her kids. She intends response to stress and illness;
to forget to take good care of and the time when treatment
herself because of her busy is sought. Individuals with
schedule. poor self-concept may feel
sad or hopeless and may state
they lack energy to perform
even the simplest of tasks.

Source:
Fundamentals of Nursing by
Kozier 7th edition p. 177

3. Role Relationship Family. ties according to Ms. Only his husband and other Support system of patient is Having a support network
Patten De Giya are good. Although relatives was there during intact. It helps in developing a (family, friends) and job
majority of her children are hospitalization considering therapeutic environment for satisfaction helps people
still young so she have all the her place and younger 8 is not acceptance and to overcome avoid and deal with illness.
time to take good care of her allowed to visit because of grieving of his lost part. Support people also provide
children and his husband. She they are prone to non- the stimulus for an ill person
doesn’t like going out socomial disease. She makes to become well again.
gossiping around her it sure that communication is
neighborhood. very important by texting Source:
using her mobile phone She Fundamentals of Nursing by
gained friends in the ward. Kozier 7th edition p. 179

24
4. Sexuality and Ms. De Giya admitted that Not sexually active. Shares openly about sexuality Menopause refers to the
Reproductive Pattern she was sexually active and reproductive pattern, change in life men when
obviously she got 6 kids. She client age and present health sexual activity decreases.
and her husband used condition would not warrant
withdrawal method and she an active sex life. Source:
never used contraceptive Fundamentals of Nursing by
pills. She’s considering Kozier 7th edition p. 398
undergo Bilateral Tubal
Ligation. Patient is no longer
sexually active since she is
pregnant. She perceived
herself as a woman secured
of his sexuality / gender and
capable of the role as mother
in her family.

5. Cognitive/Perceptual Shares the functions well at Ms. De Giya is oriented to Memory of past and present is Young Adult Hood cognitive
Pattern home. Memory about the time, place and person. No intact. Patient is aware of her and intellectual abilities
present and past is intact. No sensory deficits, responds condition and shares openly change very little. Memory
difficulties in reading. No appropriately to questions and about his situation. Shows and problem solving is very
blurring of vision. physical stimuli. She reports dependence or deficit in self- intact. They can reflect on
pain in her abdominal incision care due to his condition pass and current experiences
when being moved with a and can imagine, anticipate
pain scale of 4/10 and plan.
Source:
Fundamentals of Nursing by
Kozier 7th edition p. 400

25
6. Coping/Stress Due to her condition, Ms. De Patient is anxious. Patient’s Coping is a process that a
Tolerance Pattern Ms De Giya readily seeks Giya gets easily irritated family and coping strategies person uses to manage events
solution on stressful events because of her post partum help in building a therapeutic that he encounters perceives
encountered by his family. effect. Signs of anxiety are means of accepting his and interprets as stressful.
She and her husband work present during the assessment condition Failure to cope lead to crisis.
together to solve problems
Source:
and both respect each other
Fundamentals of Nursing by
when it comes to decision- Udan 2nd edition p. 130
making. Coping
mechanisms include
bonding with friends and
doing household chores to
distract her from problems.

7. Values Belief Pattern Ms. De Giya is a Roman Hospitalization makes Ms. De Spiritual aspects/beliefs help in One’s religious beliefs provide
Catholic. She attends masses Giya seeks guidance and helps coping with situation. strength, an inner quietness and
every Sunday. They have frequently to her faith as Hospitalization makes the faith with work with life’s
religious images at home like evidenced of “thank you lord I patient and his family to adhere problems.
Saints and Mother Mary. She thought I’m going to die to their faith as means of
often read the bible and seldom because the pain that I guidance Source:
pray to God. endured” Fundamentals of Nursing by
Udan 2nd edition p. 138

26
Ms. De Giya has no difficulty Experiences difficulty in Mrs. De Giya defecates Irregular bowel movement
of urination and defecation. defecating. No Foley catheter seldom and needs some results from lack of fiber in
Elimination He defecates daily with inserted. Urine out put is 30- laxatives as he has decreased diet, lack of exercise and
formed, brown stool and 60 cc/hr. Defecates only once activities of daily living during emotional upset.
yellow urine color. a week. her post-operative period
resulting to an increased time Sources:
for the food to move through Fundamentals of Nursing by
the large interstines where the Kozier 7th edition p. 1065-1067
water is absorbed from the
stool into the body. Physical
mobility stimulates the natural
contraction of intestinal
muscles, thus help move stools
out quickly.

Rest and Activity She’s a housewife and does She prefers resting because A great shift happened to her Exercises are needed to
not experience difficulties in she was operated via caesarean activity if she hesitate to decrease risk factors for
performing activities of daily section. She feels tired and perform early ambulation cardiovascular disease and
living. prefer taking good care on her related to her operation muscle contractures and to
new baby. increase health and wealth
being.

Source:
Fundamentals of Nursing by
Kozier 7th edition p. 1227

27
She has a good appetite. She The patient was instructed There is change if diet because An adequate food intake
like eating vegetables like Nothing Per Orem until her of her post operative consist of well balanced
Nutrition/ Metabolic Pattern “dineng -deng “and bowel movements will be procedure that may interfere essential nutrients that can
“pinakbet”. Have no known stabilizing then shifted to soft her recovery. This will aid give energy for body
allergies of food. diet. She was instructed to eat eliminating constipation. processes and movement
nutritious food for health and
her baby as well. Advised Source:
also to drink glass of water 8 Fundamentals of Nursing by
times or more a day. Kozier 7th edition p. 1171

Ms. De Giya Normally sleeps Ms. De Giya gets 5 hours of Ms De Giya rest and sleep The quantity - the total time an
six to eight hours. She wakes sleep, easily awakes but hard pattern is not normal. She individual sleep and quality-
up easily and doesn’t hard to time going back to sleep sleep-wake cycle only ranges ability to stay asleep affected
Sleep/Rest time to sleep. Sometimes she because she need to breastfeed for 5 hours though she takes by a number of factors illness
sleep late because of her her baby. If she’s given a naps. She easily wakes and has that causes by internal stimuli
children that must be taken chance she usually takes his hard time going back to sleep such as pain or physical
good care. nap after lunch. Her duo to pain and her baby. Pain distress can result in sleep
environment is one of the causes exhaustion to body problems another external
factor because of heavy crowd energy and destructs sleep stimuli which includes
and humid. cycle as it cause unpleasant environmental factors such
sensation. noise, and temperature.

Source: Fundamentals of
Nursing by Kozier 7th edition,
p 1117-1118

28
IX. ANATOMY AND
PHYSIOLOGY

BRAIN

Blood EYE
Vessels

NORMAL ABNORMAL
HEART HEART

Placenta

Kidney

Brain- It’s composed of gray and white matter within the cranium. It’s main function
serve as a control system for nervous system. The eye is the sensory organ of sight. It’s hallow
ball filled with fluid and consists of three layers namely fibrous outer layer, vascular middle
layer and inner layer. Heart- is a hallow, four chambered muscular organ that is specialized for
pumping blood through blood vessels. The kidney is made of bean shaped and vascular shape
working together from removing wastes from the body and regulates fluids and electrolytes.
Placenta serves to transport nutrients and waste secretions.

29
X. PATHOPHYSIOLOGY

Increased sensitivity to Angiotensin II


Peripheral and Vascular System


Decreased oxygen supply


KIDNEYS LIVER EYES PLACENTA

Tissue Ischemia Retinal Placental


Glomerular GF Vasoconstrictions Degeneration
degeneration R Epigastric pain
is
Na reabsorption Released of
CONVULSION Blurred Vision
Increased Thrombloplastin
permeability Water Retention like substance
Scotoma
Proteinuria Edema Oliguria Cerebral Irritability IUGR Abruptio Placenta
Rolling of
Fluid Shift from Cerebral Congestion
d ANASARCA Eyeballs
intracellular Fetal Distress
and
extracellular LUNGS Pulmonary Edema mis
Pre-term Birth
Reversible
HEAR CHF
blindness
Cerebral Edema
BRAIN
BRA
30
Severe Pre Eclampsia

PATHOPHYSIOLOGY

The symptoms of Pregnancy Induced Hypertension affect almost all organs like kidney,
pancreas, liver, brain and placenta. The vascular spasm may caused by increased cardiac output
that injures the endothelial cells of the arteries and action of the prostaglandin. Normally blood
vessels during pregnancy are resistant to the effects of pressor substances such as increased
sensitivity to Angiotensin II and nor epinephrine. In Pregnancy Induced Hypertension, this
reduced responsiveness to blood pressure changes appears to be lost. Vasoconstriction occurs
and blood pressure increases dramatically affecting the peripheral and vascular spasm.
Vasospasm in the kidney increases blood flow resistance. Degenerative changes develop in
kidney glomeruli because of back-pressure. This lead to increased permeability of the glomerular
membrane, allowing the serum proteins albumin and globulin to escape into the urine
(proteinuria). The degenerative changes also result in decreased glomerular filtration, so there is
lowered urine output and clearance or creatinine. Increased kidney tabular reabsorption of
sodium occurs. Because sodium retains fluid, edema results. Edema is further increased because
the circulatory system into the denser interstitial spaces to equalize pressure Extreme Edema will
be noticeable as puffiness in a woman’s face and hands it is most readily palpated over bony
surfaces, such over the tibia on the anterior leg, the ulnar surface of the forearm, the check bones
where the sponginess of fluid-filled tissue can be palpated against the bone and shortness of
breath. Ischemia in the liver may result in liver edema causing epigastric pain and an elevated
amylase- creatinine ratio. This will cause convulsion leading to cerebral irritability and increase
cerebral congestion accompanied with abdominal edema. Spasms of the arteries in the eyes
causing Retinal vasoconstrictions causing blurring of vision or seeing spots before the eyes.
Scotoma is one of the complications like rolling of eyeballs and reversible blindness. In Placenta
there is placental degeneration which released of thromboplastin like substances. The
affect is that arterial spasm causes bulk of the blood volume in the maternal circulation to be
pooled in the venous circulation, so woman has a deceptively low arterial intravascular volume.
Abruptio Placenta and IUGR are risks factor causing the baby to have a fetal distress which pre
term birth can be one of the complications.

31
Severe Pre
Eclampsia

XI MEDICAL AND SURGICAL MANAGEMENT

A. Medical Management

Upon admission on November 25, 2008, the patient was referred to the OB-GYNE
WARD for co-management. Upon assessment, the pregnant mother was pale and she’s
complaining in pain particularly in her abdomen. The admitting Nurses interviewed the patient.
The admitting diagnosis is Pregnancy Uterine 34-35 weeks of gestation to consider Intrauterine
Fetal Death Pre-Eclampsia Gravida 6 Para 5 (5-0-0-4) which diagnosed by the attending
physician. Her blood pressure is 170/100, Pulse Rate-79 beats per minute, and Respiratory Rate-
25 beats per minute and temperature 37.1 degree Celsius. In Generally Summary she’s conscious
and coherent. The abdominal fetal heart tone is not appreciated by stethoscope. She was asked if
she had pre-natal check up unfortunately she told that there is no pre-natal check up was done.
As we know that Pregnancy Induced Hypertension is a form of high blood pressure in
pregnancy. This is life – threatening disorder that usually develops 20 week of pregnancy. It is
typically classified as pre-eclampsia or eclampsia. In our case she’s in Severe pre-eclampsia.
Ultrasound was suggested for confirmatory and supportive measures. It was indicated in her
Pelvis with in gravid uterus is a single fetus in cephalic presentation biometric includes biparietal
diameter of 86 mm; femoral length is 64 mm, vigorous cardiac beats of 153 and estimated fetal
weight of 2224 grams. Real time study demonstrated spontaneous fetal movement with good
somatic activity. The placenta is implanted anterior heterogous with moderate on dilation of the
chorionic plate. Adequate amniotic fluid volume for age. Impression: Single viable pregnancy
cephalic presentation and alive at presentation and alive at present about 36 weeks of Age of
Gestation Grade II Maturity Placenta Norhydramnios.
On November 25, 2008 in the event that the patient will going to undergo caesarean
delivery she was ordered an I.V fluid 1 Liter of D5LR was ordered to run for 8 hours. Blood
extraction was requested to teset for CBC, blood typin, BUN, Creatinine, SGPT, SGOT,
Urinalysis, Pelvic Ultrasound, Blood Transfusion and CT. Her HbSag is non –reactive. The
attending Nurse informed patient’s condition to the doctor on duty by that time. It was properly
assessed and laboratory revealed that her condition is not safe including her baby. The doctor
ordered for Nothing Per Orem because it’s a risk for aspiration because she will going to have a
cesarean delivery. Her medications are the following Hydrazaline, Magnesium Sulfate,
Cefuroxime, Diclofenac,Tramadol, Amplodopine, Mefenamic Acid and Ferrous Sulfate. Medical
History of the patient was obtained and also the vital signs like pulse rate, respiratory rate, blood
pressure and temperature.

32
Severe Pre
Eclampsia

B. Surgical Management
Surgical interventions were done to Ms. De Giya which is Caesarean birth. Caesarean
birth accomplished through an abdominal incision into the uterus. She was scheduled as
caesarean birth through a classical cesarean incision. It was done on November 25, 2008 that
started around 6:26 pm and ended 7:20 pm.

A. Pre-operative Phase
The doctor ordered Ms De Giya to be NPO for 24 hours prior to the procedure. The
relatives of the patient were advised to secure 2 blood units of packed red blood cells to be used
for possible blood transfusion. In addition to that, an informed consent, which is vital and
necessary for an invasive procedure such as the one currently being discussed, was secured after
explaining the details of the procedure and risks involved to the patient and her relatives by the
doctor. Base line data were gathered such as vital signs. We advised the patient to remove all
jewelry and given to relative, all laboratory results pasted and incorporated to the chart, patient
made to void and catheterized by IFC , intravenous fluid checked and flowing as per ordered,
bowel preparation done and patient was advised to NPO, Pre-operation medications given and
charted and hair accessories and nail polish was removed.
C. Intra-operative Phase
After hooking to D5LR IV fluids to run for 8 hours, Ms De Giya was transferred and
placed on the operating table in a flat position. Spinal anesthesia was given between L4 and L3.
The spinal anesthesia gives was Bupinacaine 0.5% 15 mg. Skin was made prepped using
Betadine solution and sterile drape was present to block the flow of bacteria from her respiratory
tract to the incision site. The incision area on was on the abdomen and appropriate drapes was
around the area of incision, so that only a small area of skin was exposed. The incision is made
vertically through the abdominal skin and uterus.
D. Post- Operative Phase
Ms. De Giya was transferred to OB Ward after the surgical incision. Pre-operative care
was administered. Vital Signs were monitored every 15 minutes until he was stable and the
anesthesia given to her wore off. Flat on bed around 6 to 8 hours was instructed. Amount of
bleeding and discharges was noted.
On November 26, 2008 ordered by the doctor that she can may sips of clean water to
general liquids. Checking for the dressings and bowel and urinary elimination was observed
especially getting her Input and Output. Amplodipine 10 mg once a day was ordered for pain.
November 28, 2008 her diet was soft and IFC may remove. She was instructed regarding
her Planning and Discharge like her take home medicines and follow-up consultations.

33
NOLGY TEST NORMAL VALUES ACTUAL VALUES INTERPRETATION SIGNIFICAN

HBsag Non-Reactive/ Negative Non-Reactive/Negative Normal Positive- Hepatitis B

↑ infection, leukem
necrosis
te blood cells 5.0x 10^g/l 9.4x 10^g/l Normal

↓Bone Marrow Dep


Typhoid fever, mea
rubella, mononucle
hepatitis

↑ relative polycythe

d Blood Cells 4.12x10^g/l 4.04-5.48^g/l Normal ↓anemia, fluid over


greater than twenty
hours

120-170g/l-Female ↑polycythemia or
emoglobin 126 g/l Normal dehydration

↓anemia, recent hem


and fluid retention

XII. VLABORATORY TEST

IMMUNOLOGY TEST NORM AL VALUES ACTUAL FINDING INTERPRETAT

Platelet Count 150-400x10^g/l 190x10^ g/l Normal

Lymophocytes 30.0-40.0 % 27.7% Infection

34
Monocytes 0.1-0.9 g/l 0.8 x 10 g/l Normal

Bleeding Time 1-7 minutes 3 minutes Normal

35
XII. DRUG STUDY

NAME OF THE DRUG DRUG ADVERSE NURSING


DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRAINDICATIONS EFFECTS CONSIDERATIONS
Amplodopine Anti-Hypertensive Inhibits the movement Essential Contraindicated with Dizziness, light-
Besylate of calcium ions across hypertension, allergy to amplodopine, headedness, Take with meals
the membrane of alone or impaired hepatic or renal headache,fatigue,let if upset stomach
500 milligram cardiac and arterial combination with function, sickle sinus hargy,peripheral occurs
Tablet muscle cells inhibits alter hypertensive syndrome, heart block and edema, arrhythmias,
flow which utilize in lactation flushing,rash,nausea Eat frequent
the depression if and abdominal small meals if
impulse formation in discomfort vomiting is
specialized cardicac present
pacemaker cells
slowing velocity of
conduction of cardiac Monitor for
impulse, depression of irregular
myocardial contractility heartbeat,
and delation of shortness of
coronary arteries and breath, swelling
arterioles. These effects of hands or feet
had to decreased
cardiac work received
cardiac oxygen Take the Vital
consumption and in signs
patient with
vasocospastic angina
increased delivery of
oxygen of cardiac cells

36
37
NAME OF THE DRUG DRUG ADVERSE NURSING
DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRAINDICATIONS EFFECT CONSIDERATIONS

Diclofenac Anti-Inflammatory Inhibits Acute or long Contraindicated with Headache, dizziness, Take the vital
prostaglandins term treatment allergy at NSAIDS somelence, signs
3cc Deep synthetase to for post- significant renal insomnia,fatigue Take drug with
Intramascular cause antipyretic operative impairment ,rash,puritus,sweating, food or meals if
and anti- inflammatory stomatitis, constipation, G.I upset occurs
inflammatory Use cautiously with flatulence, dyspnea, renal Take only the
effects the exact impaired hearing impairment, bleeding and prescribed dose
mechanism is allergies, hepatic gastro peripheral edema Avoid driving or
unknown intestinal conditions and using dangerous
in elderly patient machinery
Report sore
throat,fever,rash,
itching, swelling,
changes in urine
and black tarry
tools

38
39
NAME OF DRUG DRUG ADVERSE NURSING
THE DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRADICATONS EFFECTS CONSIDERATIONS
Cefuroxime Antibiotic Bactericidal that Septicemia caused Contraindicated Headache, Take full course
(Medxil) inhibits of by s.pneumoniae, with allergy to dizziness, of therapy even if
bacterial cell wall S.Auerus, E.Coli, cephalosporin or lethargy, you are feeling
750 milligram causing cell death Klabishella and penicillin parasthesia, better
IV push every 8 Influenzae diarrhea Avoid alcohol
hours Use cautiously with anorexia, intake while
renal failure, abdominal pain, taking the drug
lactation and abscess at Report for sore
pregnancy. injection site throat, severe
and phlebitis diarrhea,
difficulty of
breathing,
unusual tiredness
or fatigue
Discontinue of
hypersensitivity
occurs
Check for the
vital signs like
Blood pressure,
respiratory rate,
pulse rate and
temperature

40
NAME OF THE DRUG DRUG ADVERSE NURSING
DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRADICATONS EFFECTS CONSIDERATIONS
Magnesium Antiepileptic Confactor of many Intravenous or Use cautiously Weakness, Check for the
sulfate enzymes systems Intramascular for with renal dizziness, vital signs like
involved in preeclampsia or insufficiency. fainting, BP, RR, PR and
4 grams IV push neurochemical eclampsia. Do not give during sweating, Temp.
then 5 grams deep transmission and 2 hours preceding palpitations, Assess the
Intramascular on mascular delivery because of flushing, patellar tendon
each buttock with excitability risk of magnesium depressed and reflex.
precautions presents or control toxicity in the reflexes flaccid Reserve for I.V
seizures by neonate. paralysis line for
blocking Allergy to immediate life
neuromuscular magnesium threatening
transmission products, heart conditions.
attracts and block, myocardial Monitor for
retrains water in damage, fecal magnesium level
the interstitial impaction and toxicity during
lumen and distends biliary parenteral
the bowel to obstructions. therapy.
promote mass Have a calcium
movement and gluconate readily
relieve at patient bedside
constipation. as antidote.

41
NAME OF THE DRUG DRUG ADVERSE NURSING
DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRADICATONS EFFECTS CONSIDERATIONS
Hydrazaline Anti- hypertensive Acts as directly as Severe essential Contraindicated with Nasal Take this drug
Hydochloride vascular smooth hypertension when hypersensitivity to congestion, exactly as
muscle to cause drug cannot given hydralazine, coronary headache, prescribed take
5 milligrams IV dilation primarily orally or when artery disease, mitral dizziness, with food. Do not
push for 6 hours arteriolar need to lower valvular rheumatic tremors, discontinue or
maintains or blood pressure heart disease, advanced palpitations, reduce dosage.
increase renal and urgent. renal damage and hypotension, Report persistent
cerebral blood pulmonary nausea and or severe
flow. hypertension. vomiting, constipation,
difficult in unexplained fever
micturation, or malaise, muscle
rash and joint aching, chest
urticura. pain, numbness
and tingling
sensation.
Avoid driving and
engaging task that
require mental
alertness.
Change position
slowly.
Use parenteral
drug immediately
after opening the
ampule. Withdraw
drug gradually
especially from
patient who have
exposed marked
BP reduction.

42
NAME OF DRUG DRUG ADVERSE NURSING
DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRADICATONS EFFECTS CONSIDERATIONS
Tramadol Analgesic for Central Binds to opiod Relief to moderate Contraindicated with Sedation, Limit use in
Hydrochloirde Acting receptors and to moderately allergy to tramadol or dizziness, vertigo, patient with past
inhibits the severe pain. opoids or acute headache, present history of
500 milligram IV receptors of nor intoxication with confusion, addiction or
every 6 hours for epinephrine and alcohol opoids or tachychardia, dependent opoids.
3 doses serotonin causes psychiatric drugs. nausea and Avoid driving or
many effects Use cautiously vomiting, performing task
similar to opiods constipation, rash that require
like dizziness, and puritus mental alertness.
somnolence, Report severe
nausea, nausea, dizziness
constipation but and severe
does not have constipation.
respiratory Check for the
depressant effect. vital signs like
BP, RR,CR and
Temperature

43
XIV. NURSING CARE PLAN
NURSING NURSING
INFERENCE GOALS RATIONALE EVALUATION
CUES DIAGNOSIS INTERVENTION

Subjective: Acute Pain Presence of After one hour Independent Prompt responses to After 1 hour of nursing
related to abdominal of nursing 1. Respond complaints would intervention the patient
“Hindi ako discomfort incision site intervention the immediately to immediately alleviate was able to verbalize a
makagalaw after patient will patient’s complaint pain. decrease pain
masydado dahil of pain.
caesarean verbalize a perception as
sumasakit yung surgery decrease pain evidenced by a pain
Prolonged 2. Anticipate need for Helps decrease
sugat ng tahi ko sa perception as
immobility pain relief. dependency of patient scale of 3/10
tiyan” evidenced by Encourage patient to to pain meds. diminished facial
pain scale from use non grimace, guarding
2 out of 10 pharmacologic behavior and
Objectives: Nerve damage therapy such as
diminished irritability.
guided imagery, and
facial grimace, music therapy
• (+) positive of guarding
facial grimace Nociceptors on behavior and 3. Place patient in a Supplies adequate
• Pain scale of 5 the incision site irritability semi-fowler position. blood flow to the
out of 10 area receives lower extremities.
• Presence of impulses to brain
wound Patients who request
dressings 4. Notify physician if pain medications at
interventions are more frequent
• Guarding
Brain perceived unsuccessful or if intervals than
behavior current complaint is a
in the brain prescribed may
• irritability significant change actually require
from patients past higher doses or more
experience of pain. potent analgesics

44
Providing the patient
with a conducive
5. Provide the patient a environment will help
quiet and peaceful minimize pain by
environment to be releasing endorphins
able to minimize that is a natural pain
stress and anxiety killer that abolishes
or minimizes the
sensation of pain.

Dependent: Using pharmacologic


therapy helps the
6. Administer patient increase the
analgesics as ordered speed of diminishing
perceived pain.

45
NURSING NURSING
INFERENCE GOALS RATIONALE EVALUATION
CUES DIAGNOSIS INTERVENTION

46
Subjective: Disturbed Sleep Incision site in the Short-term: Independent: Discussion makes Short-term:
Pattern related to abdomen the patient
“Hindi ako irritability and After 45 minutes of 1. Discuss understand about After 45 minutes of
makatulog ng discomfort due to nursing importance of the benefits of rest nursing
maayos dahil cesarean surgery intervention, the rest and sleep and sleep intervention, goal
sumasakit ang client will verbalize was met and the
aking sugat” Stimulation of pain understanding in patient was able to
receptors identifying verbalize
appropriate Determination of understanding in
interventions to 2. Observe and/or usual sleep pattern identifying
Objectives: and provides
promote sleep. obtain feedback individually
• Sleep at nights from client/SO comparative appropriate
4-5 hours regarding usual baseline. interventions to
Perception of pain
• Frequent travels toward the Long-term: bedtime, promote sleep as
yawning cerebral cortex rituals/routines, evidenced by
• Presence of eye After 5 days of number of hours verbalized
bags around the nursing of sleep, time of understanding of
orbital intervention, the arising. instructions
client will have
Brain perceived it improved sleeping
as pain pattern and balance 3. Encourage Long-term:
time of rest and participation in
activity as Aids in release of After 5 days of
regular exercise energy that may
evidenced by program during nursing
enhance sleep intervention, goal
6-8 sleeping hours day such as
Irritability and passive ROM was partially met as
during night time. the clients’ sleeping
discomfort exercises.
pattern improved
gradually as
evidenced by 4 to 5
4. Advise patient
47
NURSING NURSING
INFERENCE GOALS RATIONALE EVALUATION
CUES DIAGNOSIS INTERVENTION

48
Activity Ceaserean Surgery Independent: Short term:
Subjective: intolerance Short term: 1.Encourage and Establishes an After 45 minutes of
related to Cesarean After 45 minutes of educate the client excellent rapport nursing
“Hindi ko magawa Abdominal Surgery Presence of nursing and significant to the patient at intervention, the
ang mga bagay na Abdominal Incision intervention, the others about the the same time patient was able to
gusto kong gawin patient will be able benefits and the gaining show willingness in
dahil nanghihina to express and needs of doing cooperation and performing
Decrease in tissue demonstrate activities of daily respect activities of daily
ako”
absorption of eagerness in living(ADL) and living.
oxygen and participation during crutch ambulation
nutrients the performance of Long term:
the activity 2 .Encourage the Provides the After 3 days of
client to maintain patient with nursing intervention
Objectives: Decrease in oxygen Long term: positive attitude; courage and the patient was able
After 3 days of suggest the use of knowledge about to demonstrate
• Requires nursing intervention relaxation the interventions
Decrease ATP techniques such as that will help gain improvement in
assistance when the patient will
production visualization, in performing performing
changing demonstrate
guided imagery, and activities and activities of daily
position improvement in
deep breathing minimize living
Weakness performing exercises. possibility of
activities of daily anxiety
• Limited effort in living
reaching for Activity Intolerance
belongings to be
used

• Slow movement
3. Encourage Promotes good
patient to do range lung expansion
of motion and deep and circulation.
breathing exercises
49
NURSING NURSING
INFERENCE GOALS RATIONALE EVALUATION
CUES DIAGNOSIS INTERVENTION

Subjective: Self-Care Deficit: Cesarean Surgery Short term: Independent: Promotes physical Short-term:
bathing/hygiene, well-being and
“Hindi pa ako dressing After 30 minutes of 1. Discuss the comfort After 30 minutes of
nakakaligo simula nursing intervention importance and nursing
ng maospital ako” /grooming, client will be able to need of bathing intervention, goal
toileting related to Musculo- verbalize and changing of was met and client
Objectives:
musculo-abdominal Abdominal understanding about clothes daily, was able to
• Requires impairment structure the importance of good grooming verbalized
assistance secondary to S/P impairment proper/good and toileting understanding about
during ADL Cesarean Surgery hygiene. including ways the importance of
of how it will be proper/good
• Inability to done by the hygiene.
change client according
clothing to his level of
Impaired normal Long Term:
independentl ability
functioning caused Long-term:
y
by altered structure After 2 weeks of
and pain experience nursing intervention, After 2 weeks of
• With
the patient will be 2. Promote nursing
difficulty in
able to improve client/significant intervention, goal
performing
performance of self- was met and client
bathroom other’s
care activities within was able to improve
/toileting participation in
the level of own performance of self-
task Refusal to perform self-care
ability as evidenced care activities
independentl ADL by decreased activities (e.g. Enhances
bathing/ within the level of
y dependence in commitment to own ability as

50
• Poor oral performing hygiene, plan of care; evidenced by
and body dressing/grooming, dressing, demonstrates decreased
hygiene as Self-care deficit toileting and bathing. feeding) caring/concern dependence in
evidenced without interfering performing
by: the client’s effort dressing/grooming,
in achieving toileting and
○ oily independence bathing.
hair

○dry, 3. Discuss effects


scaly skin and risks for
○ halitosi non-performance For the client to
s of self care. maintain functional
self and well-being
presence of dental and to prevent
caries in teeth hazards to occur

4.Develop plan of
care appropriate to Promotes
client’s situation, consistency and
scheduling activities participation of the
to conform to client.
client’s normal
schedule

5 Provide privacy

51
during personal care
activities such as
during bathing and
dressing. In order for the
client to perform the
activities more
6. Assist with bed comfortably.
mobility such as to
encourage use of
stronger side and
unaffected part of
the body if Prevents further
appropriate. injury and to gain a
more successful
performance of
activities

52
NURSING NURSING
INFERENCE GOALS RATIONALE EVALUATION
CUES DIAGNOSIS INTERVENTION

Subjective: Constipation Cesarean Short term: Independent: High-fiber foods Short-term:


related to decreased Abdominal Incision facilitate
gastrointestinal After 1 hour of 1. Encourage client consistency of Goal was met. After
motility 2° nursing to eat foods rich stool and stimulate 1 hour of nursing
“ 3 araw na di ako intervention, the in fiber such as intervention, the
dumudumi “ decreased mobility peristalsis
client will be able to raw fruits and client was able to
Limited motion verbalize fresh vegetables verbalize
understanding of the understanding of the
Objectives: importance of importance of
defecation and able 2. Promote Fluid intake defecation and able
• Frequency: to express methods to express methods
once a week adequate oral promotes moist or
Decreased to improve bowel fluid intake such soft stool to improve bowel
• Presence of peristaltic elimination such as as high-fiber elimination such as
brown to movement in the increase in oral fruit juices, increase in oral
dark brown intestine fluid intake, intake warm water. fluid intake, intake
colored stool of foods rich in of foods rich in
fiber, fiber.
• Small
amount of anticipating urge to 3. Encourage to Anticipating urge to
dry and hard defecate and perform activity defecate and
Repressed voluntary or exercise Exercise and
stool performing performing
contraction of the within client’s physical activity
activities and activities and
• Hypoactive anal sphincter and limit and proper stimulate intestinal exercises
exercises
bowel decreased turning every contractility
sound: 10 contraction of 2hours
bowel puborectalis muscle
sounds per
minute 4. Offer a warmed
53
NURSING NURSING
INFERENCE GOALS RATIONALE EVALUATION
CUES DIAGNOSIS INTERVENTION

54
Subjective: Knowledge deficit Lack of education After 35 hours of 1. Discuss the Increase awareness After 2 hours of
regarding risk of nursing intervention importance of and it’s nursing intervention
“Hindi ko alam na pregnancy related patient will identifying the complications patient will be able
buntis ako nung to lacking verbalized and signs and to verbalize the
sinugod ako sa information identify relationship symptoms of early recognition
hospital” /misinterpretation as Misconceptions signs and symptoms pregnancy and understand the
evidenced by regarding risk of pregnancy induced risk of pregnancy
developing pregnancy and it’s hypertension it’s signs and
Objectives presentable complications symptoms as
complications 2. Encourage evidenced by
• Irritable patient and developing of
• Presence of significant preventable
eye bags Lack of Information others complications
• Refusal to talk involvement
regarding Promote self-esteem
during activities
pregnancy in part of the patient
and to able have
Knowledge Deficit continuity of care
3. Assess client’s
ability to learn

4. Providing
positive
reinforcement
To know the level
of capabilities to
think and learn

55
56
Severe Pre
Eclampsia

XV. PLANNING AND DISCHARGE

M – Medication: Mefenamic Acid 500 milligram as needed Per Orem


Cefuroxime 500 milligram tablet 3 times a day for seven days Per Orem

E – Exercise: Advise patient to perform light exercises such as stretching of the lower extremity
and upper extremity. Carrying out simple chores as form of exercise for good circulation and
faster wound healing.

T – Treatment: Emphasize to the patient the importance of wound care. Instruct the patient to
inspect the incision site daily for redness, blistering or abrasions. Use a mirror to examine all
sides and aspects of the stump. Skin breakdown on the incision site is extremely serious
because it interferes with recovery.

H- Health teaching:
 Encourage the patient to complete the prescribe medications for better therapeutic
regimen
 Hygiene for the body is also an essential to good health. Taking a bath or shower
everyday is recommended to maintain cleanliness of the body.

 Eating the amount right of food like rich in protein, vitamins and minerals to fight
infections

 Inspecting the incision site if swelling, redness and pain. If this signs are present it
may indicate inspection.

 Encourage breastfeeding not only beneficial to the mother but also the baby

 Have a new born screening to detect any complications that may arises in the future
because the mother is high risk

 Have a clean surroundings, safe and quite environment

 Promote best rest and adequate rest and sleep

O-Outpatient: Inform the patient including the relatives to notify the physician if prolonged
pain is felt and if there is presence of redness, blisters and abrasions on the incision site.
Immediate consultation must be done if there is an incidence of delayed wound healing.
OPD follow-up after discharge should also be noted including her baby for follow up
vaccine.

57
Severe Pre
Eclampsia

D – Diet:
 Instruct the patient to eat foods rich in Vitamin C such as citrus fruits, green peppers and
papaya. Vitamin C promotes wound healing; protects the body against infections, virus
and bacterial toxins; used to form blood cells; and helps decrease cholesterol in the
blood.

 Foods rich in proteins are also recommended because it helps build cells and repair
tissues.

 Fiber rich foods such as mixed vegetables, carrots, potatoes (with the skin on), corn,
rice, apples (with the skin on), oranges, oatmeal, graham crackers, and peanuts are
needed to prevent constipation. Instruct the patient to take 25-50 grams of dietary fiber.
The addition of wheat or cereals bran is essential in reaching a high-fiber intake.

 Low salt, low fat diet is also recommended to reduce serum lipid levels and avoid
excessive sodium retention. Inform him the difference between high-density lipoproteins
(HDLs) and low-density lipoproteins (LDLs) and what foods belong to each category.

 Consumption of 8 glasses of water daily is recommended to facilitate effectiveness of


the high fiber levels and also replaces fluid losses like blood, drainage, renal excretion,
etc.

 Advise patient to drink safe water to prevent certain illnesses like cholera, amoebiasis,
and typhoid fever. Teach him that for a water safe enough to drink, he should at least let
the water boil for thirty (30) minutes.
S – Spiritual: Reinforce positive behavior to the patient and his family. Encourage the family
to continue giving moral and spiritual support to the patient. Also encourage patient to
continue spiritual involvement by attending church every Sunday, praying, and reading the
bible.

58
Severe Pre
Eclampsia

XVI. EVALUATION

Conclusion and Recommendations

In general, the objective, which is to be able to discuss and analyze the case of Pregnancy
Induced Hypertension particularly Severe Pre Eclampsia, was met. This study has helped me
have a better understanding of the disease and was able to develop the right skills and attitude in
dealing with the patient diagnosed with such.

I was able to establish rapport with the patient and his family by promoting effective
nurse-patient interaction based on trust. During visits I was able to assess the patient
systematically while doing interviews. As I went along with the research of this study, I became
aware of the etiology, pathophysiology, and complications of Severe Pre Eclampsia. Also, I was
able to interpret and analyze different laboratory results which were significant in determining
the occurrence of the disease. While making the drug studies, I understood the mechanisms of
action of the drugs administered to the patient as well as the side effects which were important to
assess in order to prevent further complications. Moreover, I was able to apply effective nursing
interventions that cater to the patient’s needs by formulating nursing care plans that are
systematic, measurable, attainable, realistic, and time bounded based on the health assessment
done. In addition to that, I was also able to formulate a discharge plan appropriate for the patient.

As I analyze the case of Ms De Giya , must prioritize by allocating their budget in terns
of Health and they must try to visit nearest health care facilities or consult a doctor if she’s not
feeling well and her family Further study is suggested to formulate a more ideal medical and
nursing management for her condition.

59
REFERENCES

Pilliteri, Adele, Maternal and Child Nursing Care of the Child Bearing Family fifth edition,
Lippincott Williams and Wilkins, Philadelphia, 2007

Maternal- Neonatal Nursing Made Incredibly Easy, Lippincott Williams and Wilkins,
Philadelphia, U.S.A., 2007

Medical-Nursing Concepts and Clinical Application first edition, Udan- Quiambao, Josie,
Philippines, 2002

Human Anatomy and Physiology, Graaff and Rhees, second edition, Philippines, 1997

Nurse’s Pocket Guide, Ninth edition, Doenges and Moore, 2002

Lippincott’s Nursing Drug Guide, Lippincott Williams and Wilkins, 2007

Fundamentals of Nursing, Kozier, 2000

60